DOI:10.6084/m9.figshare.8091209 Respiratory Disease - Pediatrics Contributions made by Ryan R. Sanni of Windsor University School of Medicine

1. Respiratory
Disease - Pediatrics
Contributions made by Ryan R. Sanni -
Windsor University School of Medicine

2. Respiratory Distress Syndrome
•Shortly after birth, a 33- week
gestation infant develops tachypnea,
nasal flaring, and grunting and
requires intubation. Chest radiograph
shows a hazy, ground-glass
appearance of the lungs.

3. RDS
•Deficiency of mature surfactant
•Inability to maintain alveolar volume
•Complications: Hypoxemia -
Respiratory Acidosis, Atelectasis

5. RDS Risk Factors
•Maternal Diabetes – maternal
hyperglycemia causes fetal
hyperglycemia, fetal
hyperinsulinemia, insulin antagonizes
cortisol and blocks maturation of
sphingomyelin

6. RDS Diagnosis & Treatment
• Best initial diagnostic test – chest radiograph
• Findings: Ground – glass appearance, atelectasis,
air bronchograms
• Most accurate diagnostic test – L/S ratio (done
on amniotic fluid prior to birth)
• Best initial treatment – oxygen
• Most effective treatment – intubation and
exogenous surfactant administration

8. Transient Tachypnea of the
Newborn
•Slow absorption of fetal lung fluid
– decreased pulmonary
compliance
•Tachypnea
•Common in term infants delivered
by C-Section

9. TTN
•Best Diagnostic Test – Chest X-Ray –
fluid in fissures , perihilar streaking
•Generally improves within hours to
few days

11. Meconium Aspiration
•Meconium passed may be
aspirated in utero – pneumonitis –
respiratory failure & pulmonary
hypertension

14. Diagnosis & Treatment
• Diagnostic Best Test– Chest XRAY –
increased ap diameter, flattening of the
diaphragm, patchy infiltrates
• Prevention – endotracheal intubation and
airway suction of depressed infants with
thick meconium
• Treatment – PPV

18. Diaphragmatic Hernia
•Failure of diaphragm to close –
abdominal contents enter chest –
pulmonary hypoplasia
•Scaphoid Abdomen
•Bowel Sounds heard in chest

20. Diagnosis & Treatment
• Best Diagnostic Test Post Natal X-Ray
• Best initial treatment – immediate intubation
followed
• Followed by surgery

24. Choanal Atresia

25. Choanal Atresia
• PART OF CHARGE- CHARGE COLOBOMA , HEART DEFECTS,
ATRESIA, GROWTH RETARDATION, GENITAL HYPOPLASIA, EAR
ANOMALIES/DEAFNESS
• UNILATERAL OR BILATERAL
• SOME RESEARCH SHOW ASSOCIATION WITH TEACHER
COLLINS, FAILURE OF NEURAL CREST MIGRATION

28. Choanal Atresia
• Fails Mirror Fog Test
• Inability to pass catheter 3-4 cm into
nasopharynx
• Treatment –transnasal repair/stentIng

31. Acute Inflammatory Upper
Airway Obstruction

33. Croup
• 12 month old child is brought to your office
because of a barky cough. The mother states
that over the past 3 days the child has developed
a runny nose, fever, and cough. The symptoms
are getting worse, and the child seems to have
difficulty breathing. He sounds like a seal when
he coughs.

35. • Infective agents – parainfluenza types 1, 2, 3
• Age 3 months – 5 years, most common in winter,
recurrences decrease with increasing growth of
airway
• Signs and symptoms/examination – URI 1-3 days
then barking cough, hoarseness, inspiratory stridor,
worse at night, gradual resolution over 1 week

36. • Complications – hypoxia when obstruction is complete,
patient will worsen when inspiratory stridor turns into
expiratory stridor and then stridor at rest

38. Croup Cont’d
• Best Initial Test – Clinical Dx or CXR (steeple sign)
• Most Accurate Test – PCR for virus
• Best Initial Treatment – none or nebulized
epinephrine if severe
• Definitive Treatment if needed– single dose IM
dexamethasone then observation.

39. Nebulized Epinephrine
• Constrict arterioles in upper airway, alters capillary hydrostatic
pressure, decreases airway edema

40. Epiglottitis
• A 2 year old child presents to the emergency dept with her
parents because of high fever and difficulty swallowing. The
parents state the child had been in her usual state of health
but awoke with a fever of 104 F, a hoarse voice, and difficulty
swallowing, the patient is sitting in tripod position. She is
drooling, has inspiratory stridor, nasal flaring, and retractions
of the suprasternal notch and supraclavicular and intercostal
spaces.

42. Epiglottitis cont’d
• Infective agents – H. influena type (Hib) no longer number one
(vaccine success)
• Now combination of Strep pyogens, Strep pneumoniae, Staph
aureus, Mycoplasma
• Signs & symptoms – dramatic acute onset, high fever,
extremely sore throat, dyspnea, dysphagia, drooling

43. Diagnosis & Treatment
Epiglottis
• Best Initial Test – Laryngoscopy
• Controlled visualization (larynscopy of cherry-red swollen
epiglottis)
• Most Accurate Test – C and S from tracheal aspirate
• Best Initial Treatment – intubation
• Definitive treatment – tracheostomy if needed + 3rd
generation cephalosporins (ceftriaxone, cefotaxime) + vanco if
needed

48. Larnygomalacia
• Most common laryngeal airway anomaly most
frequent cause of stridor in infants and children
• Collapse of supraglottic structures inward during
inspiration stridor
• Less in prone position
• Starts in first 2 weeks, symptoms increase up to
6 months of life, typically worse with exertion

49. Larnygomalacia cont’d
• Diagnosis – Clinical suspicion confirmed with
laryngoscopy , bronchoscopy
• Treatment – supportive,
• surgery if significan tracheostomy

52. Congenital Subglottic Stenosis
• Second most common cause of stridor
• Recurrent/persistant croup i.e. stridor (doesn’t
get any better if patient is in supine vs prone
position)
• Diagnosis – airway xrays, confirm with
laryngoscopy
• Treatment – surgery (cricoid split or
reconstruction), may avoid tracheostomy

55. Vocal Cord Paralysis
• Third most common cause of stridor
• May be acquired after surgery from CHD or TEF repair
• Bilateral – airway obstruction high pitched inspiratory stridor
• Unilateral – aspiration, cough, choking, weak cry and
breathing
• Diagnosis – Flexible Bronchoscopy/larynscopy
• Treatment – usually resolves in 6-12 months may require
temporary tracheostomy

60. Airway Foreign Body
• A toddler presents to the ED after choking on some coins. The
child’s mother believes that the child swallowed a quarter. On
physical examination, the patient is noted to be drooling and
in moderate respiratory distress. There are decreased breath
sounds on the right with intercostal retractions

61. Airway Foreign Body cont’d
• Seen in children 3-4
• Most commonly a peanut
• Acute choking, coughing, wheezing, often a witnessed
event
• Clinically – sudden onset of respiratory distress
• Cough, hoarseness, shortness of breath
• Asymmetric wheezing, and decreased breath sounds
asymmetric
• Complication – obstruction

62. Airway foreign body cont’d
• Diagnosis – CXR will show air trapping
• Bronchoscopy for definitive diagnosis
• Therapy – removal by rigid bronchoscopy

64. Inflammatory Disorders of the
small airways

65. Bronchiolitis
• A 6 month old infant presents to the physician with a 3 day
history of upper respiratory tract infection, wheezy cough and
dyspnea, Physical exam shows temp of 102F, respirations are
60 breaths/min, nasal flaring, and accessory muscle usage,
patient appears to be air hungry, O2 Sat 92%

66. Bronchiolitis
• RSV (50%), Parainfluenza, Adeno,
• Almost all children infected are less than 2 yrs of
age
• Most severe at age 1-2 months in winter months
• Inflammation of small airways (leads to
inflammatory obstruction, edema, mucus, and
cellular debris)

68. Bronchiolitis
• Mild URI, decreased appetite and fever, irritability, paroxysmal
wheezy cough, dyspnea, and tachypnea
• Apnea in young infants
• Examination – wheezing, increasing work of breathing, fine
crackles, prolonged expiratory phase
• Lasts average of 12 days (worse in first 2-3 days)

70. Bronchiolitis cont’d
• -Immunofluorescence of nasopharyngeal swab (not routine),
PCR
• Treatment– supportive, can give beta 2 agonist nebs
• Prevention – hyper immune RSV IVIG or monoclonal antibody
to RSV F protein (palivizumab)

73. Pneumonia
• A 3 year old child presents to the physician with a
temperature of 104, is tachpneic, wet cough. Patient’s sibling
has similar symptoms. The child attends daycare but has no
history of travel or pet exposure. The child has a decreased
appetite but is able to take fluids and has good urine output.
Immunizations up to date.

75. Viral Pneumonia
• RSV
• Parinfluenza
• Influenza
• Adenovirus
• Most common less than 5 years of age
• Cold months
• Insidious
• Wheeze
• Cough
• Lower Temperature
• Worsening URI
• Mild dyspnea

76. Viral Pneumonia
• Several Days of URI symptoms
• Tachypnea
• Scattered Crackles and Wheezing
If suspect viral (outpatient) – 30% have
coexisting bacteria, if it gets works start
empiric treatment for secondary bacterial
infection

77. Viral Pneumonia
• Best Initial CXR –interstitial, hyperinflation with increased
peribronchial markings
• Accurate - respiratory secretions for viral or antigen isolation
• No treatment
• If uncertain give oral amoxicillin

78. Bacterial Pneumonia
• Strep Pneumoniae
• HiB
• S. Aureus
• Any Age, More in Cold Months
• Acute
• Severe
• Ronchi
• Rales
• Productive Cough
• High Fever
• Chest Pain
• Decreased Breath Sounds

80. Bacterial Pneumonia
• Sudden shaking chills with higher fever acute onset
• Productive cough
• Markedly diminished breath sounds, dullness to percussion

81. Bacteria Pneumonia
• Best Initial Test – Chest X Ray lobar Consolidation
• Most Accurate Test – Blood Culture, Pleural Fluid Culture
• Best Initial Treatment – admit for IV cefuroxime

82. Viral vs Bacterial Pneumonia
• Temperature – Bacterial Higher, Viral Lower
• URI – Bacterial not much, Viral Yes
• WBC – elevated in Bacterial, normal to decreased in viral
• CXR – Bacterial Lobar, Viral streaking/patchy
• Diagnosis Bacterial blood culture, transtracheal aspirate
• Viral - nasophargneal washings

84. Diagnosis
• Viral WBC less than 20K, with lymphocyte predominance
• Bacterial – usually 15K – 40K
• Definitive Diagnosis Viral – isolation of virus or detection of
antigens in respiratory tract secretions (usually requires 5-10
days), rapid reagents available for RSV, parainfluenza,
influenza, and adenovirus
• Definitive Diagnosis Bacterial – isolation of organism from
blood (positive in only 10-30% children with S. pneumonia),
pleural fluid or lung,

85. Chlamydia Trachomatis
Pneumonia
• NO fever or wheezing (RSV has fever and wheezing)
• 1-3 months of age
• Year Round
• May have conjunctivits at birth
• Stacatto Cough
• Peripheral eosinophilia

87. Asthma
• Chronic inflammation of airways
• Gold Standard – Spirometry during forced expiration
• FEV1/FVC <0.8 (80% of predicted)
• Bronchodilater response – improvement in FEV1 greater than
12%
• Exercise challenge – worsening in FEV1 of at least 15%

89. Management of Asthma
Exacerbation in ED
• Monitor Oxygen
• Inhaled albuterol q 20 for 1 hour, can add anticholinergic if no
response
• Corticosteroids PO or IV
• Can go home SaO2 greater than 92% after 4 hours in room air
• Home on 7 day oral steroid + q3-4 Metered Dose Inhaler

90. References
• https://radiopaedia.org/cases/congenital-diaphragmatic-hernia-29?lang=us
• http://learningradiology.com/archives04/COW%20089-Meconium%20aspiration/caseoftheweek89page.htm
• https://www.allthingsneonatal.com/2017/08/10/its-possible-resuscitation-with-volume-ventilation-after-delivery/
• http://sinoemedicalassociation.org/usmle1/USMLEMED6/id23.htm
• https://upload.wikimedia.org/wikipedia/commons/thumb/3/3d/Meconium_aspiration_syndrome_%28MAS%29.png/220px-
Meconium_aspiration_syndrome_%28MAS%29.png
• https://www.researchgate.net/figure/Respiratory-distress-syndrome-Note-the-ground-glass-appearance-which-
represents_fig2_49650724
• https://www.semanticscholar.org/paper/Meconium-aspiration-syndrome%3A-historical-aspects-
Fanaroff/c0a0e8c2c265af6c12b09525efae3b48ceb46add/figure/0
• https://surgery.ucsf.edu/conditions--procedures/congenital-diaphragmatic-hernia.aspx
• https://www.chop.edu/conditions-diseases/congenital-diaphragmatic-hernia-cdh
• https://steemit.com/steemstem/@winningman/all-you-need-to-know-about-choanal-atresia-and-how-we-saved-a-4-day-old-baby
• https://www.slideshare.net/OluwakemiAbegunde/management-of-choanal-atresia
• https://www.mayoclinic.org/diseases-conditions/croup/symptoms-causes/syc-20350348
• https://emedicine.medscape.com/article/962972-overview
• https://twitter.com/alaamri14121/status/897193492853686272
• https://coreem.net/core/epiglottitis/
• https://www.mdedge.com/ccjm/article/121160/infectious-diseases/concurrent-uvulitis-and-epiglottitis
• https://www.healthdirect.gov.au/tracheostomy
• https://www.mountnittany.org/articles/healthsheets/7356
• https://www.pinterest.com/pin/27514247699747776/
• https://slideplayer.com/slide/4145529/
• http://german.fansshare.com/community/uploads108/19997/flexible_fiberoptic_laryngoscopy/
• https://www.pinterest.com/pin/562738915925437537/
• https://my.clevelandclinic.org/health/diseases/8272-bronchiolitis
• https://emergencymedicinecases.com/episode-59-bronchiolitis/
• https://www.frontiersin.org/articles/10.3389/fimmu.2014.00466/full
• http://osp.mans.edu.eg/tmahdy/Students/X-Ray/CHEST/pages/LOBAR%20PNEUMONIA.htm
• https://www.mayoclinic.org/diseases-conditions/pneumonia/symptoms-causes/syc-20354204
• https://www.medindia.net/patients/patientinfo/pneumonia.htm
• Kaplan. USMLE Step 2 CK Lecture Notes 2016 – Pediatrics: Kaplan Pub; 2016

91. Thank You!